- Medicare Advantage HMOs are popular options for additional coverage not offered by original Medicare.
- In a Medicare Advantage HMO plan, services are limited to to in-network providers.
- There are many different Medicare Advantage HMO plans to choose from in each state.
- To enroll in a Medicare Advantage HMO plan, you must already be enrolled in original Medicare.
If you are planning on enrolling in Medicare, you might be considering either original Medicare with add-ons or a comprehensive Medicare Advantage plan.
There are a handful of different types of Medicare Advantage plans, but the most popular are the Health Maintenance Organization (HMO) plans. If you enroll in a Medicare Advantage HMO, your care will be provided by in-network providers.
Let’s look at what Medicare Advantage HMO plans offer, how to enroll, and some of the advantages and disadvantages of choosing a Medicare Advantage HMO plan over original Medicare.
Medicare Advantage (Part C) is a type of Medicare plan that is offered by private insurance companies. With Medicare Advantage plans, you are covered for Medicare Part A, Medicare Part B, and some additional health coverage options, such as prescription drugs, dental, vision, and more.
Medicare Advantage offers different plan structures, such as HMOs, Preferred Provider Organizations (PPOs), Special Needs Plans (SNPs), and more.
All Medicare Advantage HMO plans must cover at least:
- Part A services: including hospital insurance, hospice care, and limited skilled nursing facility and home healthcare
- Part B services: including preventive care and tests, necessary home medical equipment, outpatient procedures, and more
Most Medicare Advantage HMO plans also include:
- prescription drug coverage (Medicare Part D)
- dental, vision, and hearing coverage
- additional health coverage, such as home meal delivery or fitness memberships
To enroll in a Medicare Advantage HMO plan, you must already be enrolled in Medicare parts A and B. Once this is done, you are eligible to enroll in a Medicare Advantage HMO plan in your state.
How do Medicare Advantage HMOs work?
Medicare Advantage HMOs are based around in-network medical care. This means that you are given a list of in-network providers to choose from when you need medical services. If you decide to select a provider who is out of network, you may owe a higher cost or the full out-of-pocket amount for those services.
An exception to this rule is if you need emergency care or are traveling and require urgent care or a dialysis visit. When you enroll in your plan, you will be provided a list of in-network providers and specific rules regarding out-of-network care.
There are some types of Medicare Advantage HMO plans that allow you to seek services from out-of-network providers. These Point-of-Service (POS) plans usually have different rules than regular HMO plans.
Let’s take a look at some of the advantages and disadvantages of enrolling in a Medicare Advantage HMO plan.
Advantages of Medicare Advantage HMOs
HMO plans are a popular choice among Medicare Advantage plans, which means plenty of variety in available options. In most major cities, you can easily find plans that have low-cost premiums, deductibles, and copayments.
The popularity of Medicare HMO plans also means that you will have a wide in-network selection of providers to choose from.
Disadvantages of Medicare Advantage HMOs
There is less provider flexibility with HMOs compared with other Medicare Advantage plans. You will be required to choose a primary care physician (PCP) when you enroll in the plan, which may mean switching from your current doctor.
Referrals are required for any specialist visits, which means taking the time to visit with your primary doctor to get the referral first. Outside of emergency situations, you will owe higher costs if you seek services outside of your plan’s network.
Medicare Advantage HMO plans can be a great way for Medicare beneficiaries to
Premiums
Medicare Advantage HMO plans may have their own monthly premium, unless they are premium-free plans. Your Medicare Advantage HMO plan doesn’t cover the Part B premium, so you’ll pay this amount in addition to any premium that comes with your HMO plan.
Deductibles
Medicare Advantage HMO plans generally have their own in-network deductible amounts, which can start as low as $0. If your plan covers prescription drugs, you can expect to see a drug deductible amount, as well.
Copayments
When you enroll in a Medicare Advantage HMO plan, there are different copayment amounts for PCP and specialist visits. Copayments can range from about $0 to $50 per visit, depending on the plan and provider.
Coinsurance
After the yearly plan deductible has been met, you’ll usually pay 20 percent of the Medicare-approved costs for the services you receive.
Out-of-pocket max
All Medicare Advantage HMO plans have an out-of-pocket max that you will be expected to pay. This amount varies based on the details of your plan.
Cost comparison for Medicare Advantage HMOs in several U.S. cities
When comparing Medicare Advantage HMO plans in your state, consider all the previously mentioned cost factors. Below, you’ll find a comparison chart of various Medicare Advantage HMOs in some of the major cities across the United States.
| Plan name | Location | Monthly premium | Health deductible | Prescription drug deductible | Doctor’s visit copays | In-network out-of-pocket max |
|---|---|---|---|---|---|---|
| Aetna Medicare Select Plan (HMO) | Los Angeles, CA | $0 | $0 | $0 | PCP: $0, specialist: $0 | $2,000 |
| Kaiser Kaiser Permanente Medicare Advantage Key (HMO) | Seattle, WA | $0 | $0 | $100 | PCP: $10, specialist: $50 | $6,600 |
| Cigna Preferred Medicare (HMO) | Dallas, TX | $0 | $0 | $190 | PCP: $0, specialist: $25 | $4,200 |
| Humana Gold Plus H5619-049 (HMO) | Indianapolis, IN | $0 | $0 | $0 | PCP: $0, specialist: $35 | $3,900 |
| AARP Medicare Advantage Plan 1 (HMO) | Nashville, TN | $0 | $0 | $0 | PCP: $0, specialist: $30 | $5,900 |
| CareFirst BlueCross BlueShield Advantage Core (HMO) | Baltimore, MD | $35 | $0 | $0 | PCP: $5, specialist: $50 | $7,550 |
So, how exactly do Medicare Advantage HMOs work? What happens if you need out-of-network emergency medical care? Do specialist visits require a referral?
Here are some commonly asked questions about Medicare Advantage HMOs.
Can I keep my doctor?
If your doctor is part of the plan network, you will be able to keep visiting them for services. However, if they are outside of the network, you will either need to enroll in an HMO-POS plan or choose a different PCP to avoid paying out-of-pocket costs.
A PCP is a family medicine doctor, nurse practitioner, physician assistant, internist, pediatrician, or geriatrician. PCPs treat a wide range of health issues and can help coordinate your medical treatment with various specialists.
Do I need a referral to see a specialist?
With a Medicare Advantage HMO plan, most specialist visits require a referral from your PCP. However, certain preventative visits, such as screening mammograms, do not require specialist referral.
Do they cover prescription drugs?
Each Medicare Advantage HMO plan stipulates what type of coverage it offers in addition to Medicare parts A and B. However, most Medicare Advantage HMO plans cover prescription drugs. If you require prescription drug coverage, make sure it’s included in the plan you select.
Do I haveto go to a medical center for my services or prescription drugs?
With a MedicareAdvantage HMO, you can visit any office, medical center, or pharmacy that isaccepted in your plan’s network.
How do Medicare Advantage HMOs compare to original Medicare?
There are some key differences to consider when choosing between Medicare Advantage HMO and original Medicare. Here are some of the ways that the two types of plans differ in their coverage and costs.
| Medicare Part A coverage | Medicare Part B coverage | Medicare Part D coverage | Medigap plan available | Additional coverage options | Out-of-state care | Costs | Out-of-pocket max | |
|---|---|---|---|---|---|---|---|---|
| Medicare Advantage HMOs | yes | yes | usually included | no | yes | emergencies only | original costs + plan costs | yes |
| Original Medicare | yes | yes | can add on | yes | no | yes | original costs only | no |
Before you choose a Medicare plan, you’ll first want to figure out your personal needs. You can research plans that cover those needs.
- Medicare Advantage HMOs are a popular option for those who choose to enroll in Medicare Advantage.
- HMO plans provide a more consistent quality of care by relying on in-network providers for services.
- There are many options for Medicare Advantage HMO plans in each state, including plans with $0 premiums, no deductibles, and low copayments.
- When searching for the best Medicare Advantage plan for your needs, make sure you consider your own personal and financial situation when comparing plans.